Voluminous Cystic Trigeminal Schwannoma: Case Report and Literature Review

Voluminous trigeminal schwannomas are rare, predominantly benign growth encapsulated tumors composed of Schwann cells with controversial surgical treatment. They account for 20% to 40% of all trigeminal schwannomas and share the same imaging findings of neurinomas elsewhere. Surgery remains the treatment of choice for most lesions as long as complete excision is feasible. A 35-year-old house wife complained of a 3-month history of progressive right visual field impairment associated with headaches. Neurological examination revealed a complete cavernous sinus syndrome. CT scanning showed a voluminous cystic mass of the right parasellar compartment extending to the optic nerve and the orbit. A concomitant MRI scan revealed more exquisite anatomical details of the lesion. The patient benefitted from a subsequent CT-angiography (not included) which excluded any vascular abnormalities associated with the tumor. Surgical excision of the tumor was warranted and the patient underwent surgery a few days after admission. A pterional extradural-intradural approach combined with incision of the lateral wall of the parasellar compartment via a standard frontotemporal craniotomy was performed and pathological examination was in favor of a cystic trigeminal schwannoma. Post-operative MRI showed a complete excision of the tumor. A 2-year follow-up yielded persistent right monocular blindness. Given this typical appearance of this lesion indicative of both cisternal and parasellar compartment extension, as well as the level of controversy surrounding surgical treatment of these particular tumors;we sought to report this rare case of a voluminous cystic trigeminal schwannoma and share our humble surgical experience of dealing with these lesions. The patient was informed that non-identifying information from the case would be submitted for publication, and she provided consent.

Surgical Clipping of a Basilar Tip Aneurysm: Case Report and Literature Review

Basilar tip aneurysms account for 5% - 8% of all intracranial aneurysms. They are known to rupture more frequently than aneurysms in other locations. Surgical clipping of basilar apex aneurysms however challenging;remains the treatment of choice in Ivory Coast due in part, to multiple technical barriers. A 60-year-old right-handed patient presented to our Neurosurgical Unit in February 2nd 2013 after a sudden onset of altered consciousness. Neurological examination revealed both an upper motor neuron and meningeal syndromes with a Glasgow Coma Scale of 12. Brain NECT scan and a subsequent brain CT angiography showed a subarachnoid haemorrhage and a 3.8 mm (height) × 5.2 mm (width) basilar tip aneurysm respectively. Surgical clipping of the aneurysm was indicated but due to multiple technical barriers, surgery was delayed and the patient underwent surgery after the critical vasospasm period. The patient developed a hospital acquired pneumonia after surgery and was successfully treated with antibiotics. Since her discharge, she has been asymptomatic. We sought to report this case of a basilar apex aneurysm successfully occluded with non-ferromagnetic SUGITA clips and to share our experience of clipping these lesions through the frontotemporal approach. The patient was informed that non identifying information from the case would be submitted for publication, and she provided consent.

Pericallosal Artery Aneurysms: Twenty-Six Years of Microneurosurgical Endeavor in Three Major Neurosurgical Centers in Abidjan

We present our experience of microsurgical treatment of pericallosal artery aneurysms (PCAA) in three neurosurgical centers in Abidjan (Ivory Coast) from 1990 to 2016. This present study aimed to evaluate characteristics of 6 patients with PCAA treated during a 26-year period and to establish the rate, clinical nuances, anatomical variations and respective microsurgical approaches of PCAA in Abidjan. We analyzed medical files of all 93 patients admitted for an intracranial aneurysm between 1990 and 2016 and focused on the 6 patients who were treated for a PCCA. The mean age of patients was 37 years, half of whom were less than 30 years old. They were 3 men and 3 women. The time from first symptom to admission was more than 3 days, but less than 16 days. Five out of six patients had ruptured aneurysms and the clinical condition on admission was WFNS grade 0 one patient (16.67%) and WFNS I-III five patients (83.33%). Analysis of radiological data revealed Fischer grade IV three patients and Fischer grade I-II three patients. A total of 7 PCCA were recorded and they accounted for 6.19% of all intracranial aneurysms and 9.72% of all anterior circulation aneurysms. Six out of seven aneurysms (85.71%) were either smaller (2 - 6 mm) or middle sized (6 - 15 mm). There was only one (14.29%) giant PCA aneurysm (>25 mm). According to the location, two aneurysms (28.57%) were located on the A2 segment of the pericallosal artery (PCA) and five (71.43%) on the A3 segment of the artery. We found 4 cases of saccular aneurysms (57.14%) and 3 cases of fusiform aneurysms (42.86%), two of which were located on A2 segments of the 2 PCA on the same patient (16.67%). We didn’t find any PCA anatomical variation associated with any of the 7 aneurysms. Two patients developed perioperative rebleeding and in 1 case a severe preoperative hydrocephalus was diagnosed. The median time from rupture to surgery was 59.5 days with a range of 14 to 180 days. Treatment techniques included 4 clipping (57.14%) and 3 wrapping (42.86%). In 2 cases there was premature perioperative rupture of the aneurysm (33.33%). One patient (16.67%) had postoperative persistent anosmia and, we didn’t record any fatal outcome in our series. PCAA remain rare anterior circulation aneurysms, located in the vast majority of cases, on the A3 segment of the PCA and, are mostly smaller in size even when ruptured. Microsurgical clipping remains a safe and effective treatment option despite their complex surgical approaches and the risk of premature rupture.

Late Post-Traumatic Cerebrospinal Rhinorrhoea

Cerebrospinal fluid (CSF) rhinorrhoea results from anatomical breach between the subarachnoid space and air sinus cavities of the skull base and traumatic CSF rhinorrhoea accounts for 80% - 90% of all cases of CSF leaks. We sought to report the case of a 16-year-old patient with a history of head injury following a fall from a tree, who developed a post-traumatic CSF rhinorrhoea after an onset of meningitis. The patient sustained a fall from a 6-meter tree in 2008, and was reviewed by our neurosurgical team in February 2016 for a 1-month history of progressive headaches associated with fever, asthenia and left CSF rhinorrhoea. Clinical examination revealed frank meningism and abundant CSF leak from the left nostril. CT scanning showed fractures of the left frontal bone and sinus wall associated with a massive pneumocephalus. The patient benefited from surgical repair of the tear and post-operative lumbar punctures at day 15. The patient’s guardian was informed that non-identifiable information from the case would be submitted for publication and he provided consent.

Vertebral Localization of Multifocal Skeletal Tuberculosis: Case Report and Literature Review

Multifocal skeletal tuberculosis is a rare condition. The diagnosis is difficult and the treatment is delayed in the vast majority of cases. A 30-year-old immunocompetent jobless male complained of thoracic and lumbar spine pain for several weeks, associated with progressive weight loss without fever. Neurological examination was normal. CT scanning demonstrated hypodense multifocal lesions of the spine and the hip. Vertebroplasty was performed successfully. But a pathological examination of the biopsy of spinal lesions was not conclusive. One month later, the patient developed an acute spinal cord compression syndrome. Emergency decompression surgery was performed, which demonstrated the purulent epidural abscess and osteolysis. The pathological examination was in favor of tuberculosis. Despite surgical stabilization and cementoplasty, anti-TB therapy and kinesitherapy, the patient was still significantly limited a few months later with a flaccid paraplegia. TB infection was cleared at the end of the two-phase regimen. Atypical tuberculosis ormultifocal TB poses diagnostic problems especially with metastases, malignant lymphoma, and multiple myeloma. We report this rare case of mutifocal skeletal tuberculosis to show the place of vertebroplasty in the management of spinal tuberculosisor if there is indeed a potential role that vertebroplasty could have played in spreading spinal lesions. The patient was informed that non identifying information from the case would be submitted for publication, and he provided consent.